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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1778969

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Case Details

VAERS ID: 1778969 (history)  
Form: Version 2.0  
Age: 87.0  
Sex: Female  
Location: Kansas  
   Days after vaccination:211
Submitted: 0000-00-00
Entered: 2021-10-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006M20A / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, COVID-19, Chills, Dyspnoea exertional, Dysstasia, Hypoxia, Nasopharyngitis, Pain, Productive cough, Pyrexia, SARS-CoV-2 test positive
SMQs:, Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Chief Complaint via EMS patient reports increased weakness today after outpatient MAB infusion at LMH, unable to stand on own. COVID+ on Saturday. 38.8 in triage, hx of HTN. + generalized aching, chills. History of Present Illness 88yo woman with h/o HTN, paroxysmal afib, 2015 TIA, OSA, prior DVT, obesity, who had COVID vaccination with Moderna earlier this year. Was in usual state of health until trip to another state, last week. Then 3 days ago tested positive for COVID after feeling like she had a head cold. Received antibody infusion yesterday, and weakness became so profound that she went to her knees. Some DOE and cough that is minimally productive as well with no bloody component. Did not really feel the fever she had on arrival. No GI symptoms. No syncope, rashes, other pain. Was surprised that she was hypoxic on ED arrival.

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